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Anxiety, ADHD and Reading Disorders – How They Interconnect and How to Help April 29, 2015 Robert L Hendren, DO Professor of Psychiatry and Behavioral Science Co-Director, UCSF Dyslexia Center

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Anxiety, ADHD and Reading Disorders – How They

Interconnect and How to Help

April 29, 2015

Robert L Hendren, DOProfessor of Psychiatry and Behavioral Science Co-Director, UCSF Dyslexia Center

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Anxiety •  People with dyslexia may experience marked anxiety

in situations in which they worry they will make a mistake or be ridiculed in front of others

•  The stress response is our body’s attempt to keep us safe from harm and is a biological and psychological response and anxiety is the worry about stress

•  Too much or too little anxiety does not result in the optimal outcome

•  Anxiety builds the more we feel we cannot control the outcome and can ultimately lead to “freezing”

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Anxiety and Dyslexia •  Anticipation of failure can raise anxiety in new

situations and lead to avoidance

•  Frustration can lead to anger which can be targeted at school, teachers and parents

•  Parents can be the targets because they are trusted. By adolescence, this can lead to breaking away if they are feeling too dependent

•  Negative thoughts can lead to depression

•  All of this can lead to family stress with parents and siblings

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Dyslexia and Anxiety Disorders •  Increased internalizing, anxious, and depressive

symptomatology in dyslexia (Whitehouse, 2009). Severity depends on comorbidity with ADHD, perceived social support and female gender (Mugnaini, 2009)

•  Compared to college students without RD, up to 5 times as many college students with RD report clinically significant test anxiety (Nelson, 2013). General anxiety is higher too (Carroll, 2006)

•  Parents of children with dyslexia have a similar cognitive, emotional and behavioral profile as their children (Bonifacci, 2014)

• 

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Anxiety: What It Looks Like •  Hypervigilant

•  Reactive to novel stimuli

•  Cope by avoidance

•  Parental accommodation; over protection

•  Physical symptoms

•  Inattention and poor performance at school

•  Becomes most noticeable at 6 to 12 years of age

•  Very common – Lifetime prevalence 14 – 27%

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Other Symptoms •  Explosive outbursts

•  Easily overwhelmed

•  Extremely sensitive, readily tearful

•  Fears and/or preoccupation with death, dying

•  Avoidance of outside and interpersonal activities, such as school, parties, camp, sleepovers, safe strangers

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Course of Anxiety •  20% of children with dyslexia also have anxiety

disorder and another 20% have a depressive disorder

•  Childhood onset of anxiety has high risk of progression to depression

•  Intense symptoms may diminish

•  Emotional symptoms may interrupt the learning process

•  Symptoms and failure in major roles may come in adulthood for some

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Anxiety Disorders •  Separation Anxiety Disorder

•  Generalized Anxiety Disorder

•  Social Anxiety Disorder

•  Obsessive Compulsive Disorder

•  Post Traumatic Stress Disorder

•  Panic Disorder

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Separation Anxiety Disorder

•  Excessive concern regarding separation from home or from attachment figures

•  Bad things happening to loved ones •  Cannot be alone •  Difficulty falling asleep; sleeping with loved ones •  Physical aches and pains •  Accommodation by caretakers •  Strategies to maintain proximity to primary

caretakers •  Decoding performance predictive (Grills-Taquechel,

2012)

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Generalized Anxiety Disorder •  Excessive worry and apprehensiveness

•  Restless, keyed-up, or on edge •  Fatigued at the end of the school day •  Concentration problems; performance anxiety •  Difficulty falling asleep •  Tense and irritable •  Excessive need for reassurance – many questions •  Over studying

•  Unable to control the worry

•  Impairment or distress

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Social Anxiety Disorder •  Intense fear of being scrutinized and judged

by others in social or performance situations

•  Avoidance of social situations

•  Physical symptoms of anxiety including confusion, pounding heart, sweating, shaking, blushing, muscle tension, upset stomach, and diarrhea.

•  Children may express their anxiety by crying, clinging to parent or throwing a tantrum

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Obsessive Compulsive Disorder •  Prominent obsessions and/or compulsions

•  Dirt, germs or other contamination •  Ordering and arranging •  Checking •  Repetitive acts •  Over-valued ideas •  Hoarding

•  Impairing or time consuming

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Posttraumatic Stress Disorder •  True stressful event – life threatening

•  Re-experiencing the event

•  Avoidance and numbing

•  Increased arousal

•  Negative thoughts, feelings, moods

•  Risks for enduring symptoms

•  Pre-existing mental disorder •  Proximity •  Posttraumatic environment

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Panic Disorder •  Attacks of anxiety (physical symptoms)

•  Increased heart rate, pounding heart, palpitations •  Hyperventilation •  Choking sensation •  Chest discomfort or pain •  Abdominal pain •  Some psychological symptoms

•  Worry about the next one

•  Avoidance behavior

•  Agoraphobia

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Assessment Strategies •  Multidimensional Anxiety Scale for Children

(MASC)

•  Screen for Child Anxiety Related Emotional Disorders Scale (SCARED)

•  Search “U Pitt SCARED”

•  Achenbach Child Behavior Checklist (CBCL)

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Understanding Anxiety and Dyslexia

•  Lack of understanding the basis of dyslexia may result in self-blame and self-doubt

•  The DE-STRESS Model for dyslexia www.eida.org/the -dyslexia-stress-anxiety-connection/

•  Define •  Educate •  Speculate •  Teach •  Reduce threat •  Exercise •  Success •  Strategize

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Decrease Bad Anxiety •  Yoga

•  Mindfulness

•  Meditation

•  Biofeedback

•  Exercise

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Anxiety Disorders Treatment •  Positive reframing

•  Thought challenging

•  Control through competence

•  Cognitive Behavior Therapy

•  Psychoeducation •  Functional assessment •  Exposure treatment •  Family change •  Parents as coach

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SSRI Medications for Anxiety Disorders

•  Fluoxetine (Prozac) – Effective for OCD, MDD, SAD, GAD, SoP

•  Fluvoxamine (Luvox) – Effective for OCD, SAD, GAD, SoP

•  Sertraline (Zoloft) – OCD, SAD, GAD, SoP

•  Paroxetine (Paxil) – OCD, SoP,

•  Citalopram (Celexa) no controlled trials in children

•  Escitalopram (Lexapro) – FDA approved to age 12 for depression

•  Duloxetine (Cymbalta) – FDA GAD 7 years and older

•  Venlafaxine (Effexor) – Effective for SoP but ? GAD

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Training for Awareness, Resilience, and Action (TARA)

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The 12-week TARA group program

Module 1: Calming Down and Creating a Sense of Safety

Module 2: Attending and Caring about Our Inner Experience

Module 3: Recognizing, Regulating, and Communicating Emotions

Module 4: Core Values, Goal Setting and Committed Action

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Co-occurrence of Reading Disorder & ADHD

Learning disorders are often overlooked and undertreated in children with ADHD (Hong DS, JAACAP 2014)

High degree of overlap of genetic, neuropsychological and brain differences

15% to 45% of children with ADHD (inattention) also have RD (Hechtman, 2005; Sciberras et al., Pediatrics, 2014)

RD and ADHD share a common cognitive deficit in processing speed suggesting common genes (Willcutt, Cortex, 2010)

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Things to Love About ADHD •  Scanning Focus •  Hyperfocus •  Resilience and commitment •  Ingenuity •  Willing to take risks and spontaneity •  Funny •  Anything is possible •  Persistence •  Different perspective •  Motivational

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Famous People with ADHD

•  Albert Einstein •  Michael Phelps •  Cher •  Walt Disney •  Richard Branson •  Michael Jordan •  Justin Timberlake •  Will Smith •  Jim Carrey •  Paris Hilton

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ADHD: Core Symptom Areas

Inattention

Impulsivity/ Hyperactivity

DSM V Diagnosis:

•  Predominantly inattentive type

•  Combined type

•  Predominantly hyperactive- impulse type

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Distractible Inattention (Executive Function)

•  Unsustained attention, doesn’t listen, doesn’t follow through

•  Disorganized, avoids mental effort, loses things

•  Easily distracted, forgetful

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ADHD Low self esteem

Academic limitations

Relationships

Smoking and substance abuse

Injuries Motor vehicle accidents

Legal difficulties

Occupational/ vocational

Adu

lts

Adolescents

Potential Areas of Impact

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Rating Scales •  ADHD-RS

•  Connors’ ADHD Rating Scale

•  Vanderbilt Assessment Scales

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Integrated Pharmacologic Treatment

•  Psychoeducation for patient and family

•  Management of medications

•  Cognitive-behavior therapy

Horst RO, et al. Essent Psychopharmacol. 2005;6(5):250-261. Rostain AL, et al. J Atten Disord. 2006;10(2):150-159. Knouse & Safren. Psychiatr Clin North America. 2010; 33(3):497-509

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Stimulants Methylphenidate HCl (Ritalin) 10-60 mg/day

Methylphenidate extended-release (XR) (Concerta) 18-72 mg/day

Methylphenidate HC (Methlylin ER), Methylphenidate HCl HR (Metadate ER/CD), methylphenidate (Ritalin SR/LA); Quillivant XR

Dexmethylphenidate hydrochloride XR (Focalin XR) 2.5-40 mg/day

Dextroamphetamine (Dexedrine) 5-60 mg/day

Amphetamine mixed salts (Adderall, Adderall XR) 5-60 mg/day

Vyvanse (lisdexamfetamine) 20 – 70mg/day

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Comparing Stimulants

•  Equal efficacy across methylphenidate and dextroamphetamine

•  Approximately 70 - 80% respond

•  Response rate may be as high as 96%

•  Some individuals have stimulant-specific responses

Greenhill LL et al. (2002), J Am Acad Child Adolesc Psychiatry 41(2 suppl):26S-49S

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Stimulant Adverse Events •  Decreased appetite

•  Insomnia

•  Rebound effects

•  Tachycardia, palpitations, hypertension

•  Tics

•  Growth suppression

•  Psychosis

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Newer Treatment Options Daytrana - Methylphenidate transdermal system (MTS)

Wear patch for up to 9 hours 10 – 30 mg titrated up

Vyvanse - Lisdexamfetamine (L-lysine-d-amphetamine)

“Prodrug” decreases abuse potential Capsule can be dissolved in water and still has 12 to 14 hour duration

Quillivant XR (liquid methlyphenidate)

5mg/ml comes as 25mg/5ml Start: 20 mg PO qam, may incr. by 10-20 mg/day q7 days; Max: 60 mg/day; Info: duration 8-12h

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Atomoxetine (Strattera) Blocks presynaptic norepinepherine transporter with no

significant dopamine effect

Similar improvement in ADHD symptoms to methylphenidate, but perhaps less improvement in inattention

Modest improvement in depression and anxiety if present

Improves social and family functioning

Dosage: 18-100 mg once/day

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Atomoxetine (Cont.)

Adverse effects in children: decreased appetite, nausea, abdominal pain, dizziness, somnolence

Possible decreased height and weight with longer term treatment

Caution with poor CYP2D6 metabolizers

FDA warnings: liver toxicity, suicidal thoughts in children

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Adrenergic Stimulating Agents

Symptoms - anxiety, sleep disturbance, PTSD, hyperactivity, impulsivity

•  Clonidine (Catapres, Kapvay)

•  Guanfacine (Tenex, Intuniv)

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Unproven (but maybe effective)Treatments

•  EEG biofeedback training •  Dietary manipulation: oligoantigenic diet •  Megavitamin therapy •  Herbal treatments •  Manipulation: body and craniosacral •  Sensory integration training •  Anti-yeast medications •  Supplements (Acetyl-L-carnitine, essential

fatty acids, Ginko biloba) •  Micronutrients

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Neurofeedback and Cogmed Working Memory Training

•  A Meta-anlysis of EEG-NF found 5 RCT studies with 263 patients and found improvements in overall ADHD score, inattention score and hyperactivity/impulsivity score compared to controls1

•  Review of pharmacological and psychosocial treatments for ADHD found no evidence that cognitive enhancement trainings improved functioning of adolescents with ADHD2

•  Meta-analysis of neurofeedback in ADHD found large effect sizes for inattention and impulsivity and medium effect sizes for hyperactivity3

•  7 studies of Cogmed Working Memory Training suitable for review found mixed findings concluding the strengths and limitations suggest “Possibly Efficacious Treatment for ADHD”4

1Micoulaud-Franchi, et al Front Hum Neurosci, 2014 2 Sibley et al, Clin Psychol Rev, 2014 3 Arns et al., Biol Psychol, 2014 4 Chacko et al., J Clin Child Adolesc Psychol, 2013

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